management of cecal volvulus - department of surgery at ... · diagnosis and treatment of caecal...

Christopher LauKings County Hospital

SUNY Downstate Medical CenterFebruary 24, 2011

www.downstatesurgery.org

37 year old male presented with 1 day history of abdominal pain

Pain was diffuse but worst in the epigastric area No fevers or chills No nausea or vomiting No diarrhea or constipation Last BM and flatus 1 day prior


PMH: lumbar disc herniation PSH: appendectomy in childhood No allergies Medications: Toradol, cyclobenzaprine


T 97.5, BP 114/73, HR 75, RR 18 Gen: AAOx3, NAD CVS: S1S2, regular rate and rhythm Chest: CTA bilaterally Abd: soft, mild diffuse tenderness and distension,

decreased bowel sounds, no rebound or guarding, healed RLQ scar

Rectal: normal, no masses, guaiac negative


CBC: 5.16>14.3/43.1<211 Chemistry: 138/4/101/26/12/1.03<94, Ca: 10.8 LFT: 7.8/4.8/35/32/65/0.6 Lactate: 1.6 Coags: 11.4/27.7/1.1


Exploratory laparotomy via midline incision Severely dilated cecum was brought out and found to

be volvulized Bowel was pink and viable Volvulus was reduced Ileocecectomy with primary anastamosis performed Notably the patient had a very long small bowel

mesentery and very redundant transverse and sigmoid colon


POD 1-2: NPO awaiting bowel function POD 3: NG tube removed and clear liquids tolerated POD 4: Tolerating regular diet POD 5: Discharged home

Pathology: Cecum 10cm in greatest diameter, thin walled. Markedly thinned bowel mucosa with prominent thickened vessels consistent with volvulus.


Axial twisting involving the cecum, terminal ileum, and ascending colon (90%)

A variant is cecal bascule (10%) An upward anterior folding of the cecum

Responsible for 1% of intestinal obstructions 18-44% of colonic obstructions

Age at presentation is affected by cultural and dietary factors

Average age at presentation is 53 in Western countries


Incomplete intestinal rotation during embryogenesis Inadequate fixation of the right colon to the

retroperitoneum 11-25% of the population have a cecum that is

sufficiently mobile to allow torsion Risk Factors

Previous abdominal surgery High fiber intake Chronic constipation Adynamic Ileus Distal colonic onstruction


Recurrent intermittent May occur in up to 50% before onset of acute volvulus Recurring right lower quadrant abdominal pain and

distension Acute obstructive

Presentation similar to small bowel obstruction Difficult to distinguish based on clinical exam May progress to strangulation and perforation

Severe abdominal pain, peritonitis, hemodynamic instability


X-ray Cecal dilation 98-100% Single air-fluid level 72-

88% Dilated small bowel 42-

55% Findings are non-

specific


Barium enema Diagnostic accuracy

88% Smooth tapering cut off

(“beak sign”) is the most common confirmatory finding

Occasional successful reduction

Potential for contrast extravasation


Abdominal CT Recommended when x-ray and clinical exam

inconclusive Replacing barium enema as study of choice Common CT findings:

“coffee bean” sign “whirl” sign “bird beak” sign

May sometimes see gas-filled appendix May help identify ischemia and perforation


Value is limited Success rate of reduction is 30% Risk of perforation Delays operative treatment Because of high risk of bowel ischemia, operative

treatment is usually required Generally not recommended


No prospective treatment trials Options include:

Choice of procedure is surgeon and patient dependent

Procedure Recurrence

Operative detorsion 0-70%

Cecopexy 0-40%

Cecostomy 0-30%

Colectomy No reported recurrence


Determine viability of bowel Gangrenous cecum is reported in 23-100% Non-viable bowel requires resection

Avoid detorsion which may lead to irreversible shock Clearly viable bowel may be detorsed and treated with

fixation vs. resection Manual detorsion alone is not recommended


Several case reports of laparoscopic cecopexy for cecalvolvulus

May be a viable options Needs further assessment No reports of laparoscopic colectomy for cecal volvulus

Baldarelli M, De Sanctis A, Sarnari J, Nisi M, Rimini M, Guerrieri M. Laparoscopic cecopexy for cecal volvulus after laparoscopy. Case report and a review of the literature. Minerva Chir. 2007 Jun;62(3):201-4.

Shoop SA, Sackier JM. Laparoscopic cecopexy for cecal volvulus. Case report and a review of the literature. Surg Endosc. 1993 Sep-Oct;7(5):450-4.


Cecal volvulus occurs mostly in those with developmental predisposition who are exposed to environmental risk factors

Diagnosis is most commonly by x-ray and CT findings Treatment options include fixation and resection

procedures Colonoscopy is not recommended Laparoscopic fixation may be an effective option


Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J. 2005 Dec;81(962):772-6.

Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. 2002 Feb;45(2):264-7.

Baldarelli M, De Sanctis A, Sarnari J, Nisi M, Rimini M, Guerrieri M. Laparoscopic cecopexy for cecal volvulus after laparoscopy. Case report and a review of the literature. Minerva Chir. 2007 Jun;62(3):201-4.

Shoop SA, Sackier JM. Laparoscopic cecopexy for cecal volvulus. Case report and a review of the literature. Surg Endosc. 1993 Sep-Oct;7(5):450-4.

Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. DisColon Rectum. 1990 Sep;33(9):765-9.

Cameron: Current Surgical Therapy 10th edition


management of cecal volvulus - department of surgery at ... · diagnosis and treatment of caecal...

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